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September 2004, Volume 54, Issue 9

Case Reports

Sexual and Reproductive Health Promotion at the Grassroots; Theater for Development - a case study

H. A. Afsar  ( Aahung, Karachi )
S. Gill  ( Aahung, Karachi )

Introduction

Theater is now well established in many parts of the world and has been used extensively especially in the field of HIV/AIDS prevention1,2 and family planning.3,4 It has also been an instrument for community development and women empowerment.5 It has proved popular both with adults as well as adolescents6,7 and has shown to be particularly instrumental in dealing with sensitive issues like genital mutilation.8 However its use and effective implementation as a coherent set of sustainable development practices is still very rare. Aahung in its role as a resource center for sexual health developed a training module called 'Theater for development in sexual health'. The following is a commentary on the rationale, uses and methodology of TfD followed by a case study of the above-mentioned training module.

A person's sexuality, although linked to his/her reproductive health, is a distinct but very much a part of one's general health and well being. Sexuality is not just about sexual acts and behaviors; it is about attitudes, identities, thoughts and feelings. Being sexually healthy allows a person to experience one of the most intimate forms of contact with another human being, which can be a source of both intense physical pleasure and emotional fulfillment.

As it can be enjoyed, sexuality can also be abused and violated. Child and forced marriage, child sexual abuse, marital rape and sexual assault are some extreme ways in a person's right to his/her body is violated. Infections and diseases like Hepatitis and AIDS, acute and chronic STIs can impair a person's health and well being irreparably. Being sexual healthy means having the capacity to control and enjoy sexual behavior in accordance to one's personal values.

Changing Attitudes

Although providing accurate information is an important aspect of improving sexual health, no change will be affected if people choose not to avail that information or a service. A family-planning clinic, for example, cannot provide services to people who are not willing to use them. Attitudinal change therefore, in addition to information giving, is vital in order to promote safe and responsible sexual behavior. In order to bring about attitudinal change, it is important to examine the motive and beliefs behind the behavior. In other words, if a woman is resistant to family planning, one may have to explore her fears/ concerns behind the resistance. Often these fears are important functions of behavioral intent and have been acknowledged as an important phenomenon to observe and understand when designing health promotion strategies.9 More often than not, these fears are a result of myths and misconceptions. A person's attitude is a result of and is affected by environment, education, traditions and cultural norms. This process starts when we are born and continues for the rest of our lives. Affecting change in a person's attitude therefore is a gradual process and cannot be effectively achieved over night.

In recent years, health education has undergone a transition from the 'victim blaming' model, with a focus on fear as the main motivation of behavior, to more empowering models. Research has demonstrated that fear and guilt as motivations of behavior have a limited long-term effect. In some instances it may even cause people to ignore messages altogether because they are put off by the information or adopt avoidance behaviors to reduce anxiety about what they fear leading to more risky behaviours.10 An ideal health program should therefore not only provide correct information but also explore values and attitudes, teach skills and empower people to make healthy decisions to enable behavior change. This can be done on a personal one to one basis such as a health visitor/ client or teacher/pupil; or in groups such as smoking cessation classes, or by means of reaching large audiences as in mass media campaigns. Hence the need is not just information giving, but enhancing the person's ability to understand and conceptualize the message, that is, empowering the individual to make the 'correct' decisions based on their ethical and moral values.

Theatre and Development

Throughout recorded human history, and in all cultures, communities have used various art forms as a means of expressing their relationships with the environment and social realities in order to better understand them. Among these forms theater has always held a special place as an art form that works with the human body as its medium, offering images which provide a commentary upon reality and offer alternatives to the perceived realities in which a given community lives.11 Theater tries out possibilities in the knowledge that the consequences are never fatal; the dead character is restored to life and the story can be tried out in a different way. In fact theater may very well be the most democratic of art forms. Not only can anybody do it, everybody does it, whether wittingly or unwittingly in our daily lives, as roles are played out in ways that are necessary for the survival and working of society.

Theater has been described as a key process for social change.12 It allows participants the chance to try out roles, which they would be denied in real life. Peasants can be landlords and more rarely landlords can be peasants. Women men and men women. All forms of violation can be explored and all norms of reality challenged. If development is considered as a process in which people's conditions-material, social, political or cultural- are changed, then theater, with its immense transformative potential seems to be an ideal form through which to explore a community's developmental aspirations and possibilities.13

Theatre for Development (TfD)

Theater for Development (TfD) is just what it says; theater used in the service of development aims. As a tool it can be instrumental for development agencies which pursue the goals of self development and an improved quality of life of all people whose material conditions leave them vulnerable to hostile, predatory forces, both natural and human.12 In other words it is an instrument in the struggle to help such people become the subjects, and cease to be the objects of their own histories.

Interest in TfD started in the late 60's and 70's international movement for popular theater, was what theater for development was called at that time. Popular theater was a theater that mobilized communities for social change. One of the notable figures in popular theater then was Augusto Bowal who wrote a book called "theater of the oppressed" and this became the stepping stone for development of TfD.

The major strength of TfD is that there is no pre set notion as to what the play should be about. The community suggests the plays and community problems are the focus of the drama not just depicting those problems but also trying to get to a point where the community would do something about the problem. So it is very much theater of community empowerment.

The emphasis in TfD is not the product of the process, the play, but on the process itself because in that way learning will take place at every stage of the process, and even after the session has ended. If emphasis is on the performance of the plays-the products- then all they will think of afterwards is how "good" they were. Differences in opinion are encouraged instead of being avoided so that they may be explored and the best options 'discovered'. Participants are made to feel that they speak their own language, rather than having messages 'pushed down their throats'. As it is, TfD is not meant to be sermonizing. Nor should it be an advertisement for any program government or otherwise. Nowhere may the viewer be shocked but sees everyday realities depicted with a simultaneous subtle critique of the same. The spectators are expected to come to terms with their own consciousness regarding the issues raised through these scenes. Feelings can range from justification, distrust and escaping the accusation to frustration, realization and even enlightenment.

Case Study

Jindodhero is a relatively large village of 430 households and a population of approximately 5,000 inhabitants situated about 35 kilometers from Larkana City, Sindh. The Village Development Welfare Association (VDWO), a local CBO funded by Strengthening Participatory Organization (SPO), started work in 1997 with a small micro-credit scheme. Over time, it has gained a good reputation with the locals and works with the local government on developmental schemes in the village. A workshop called 'Theater for Development in sexual health" was arranged on request of VDWA and was conducted in Larkana city, and facilitated by three trainers from Aahung. Fourteen participants who included four females took part in the workshop.

The five-day TfD workshop was especially designed with the objectives to (1) introduce the concept of theater for development/positive change, (2) to practice various theater games, (3) to clarify concepts and importance of positive sexual health, (4) to sensitize participants on participatory methods of learning/facilitation, (5) to enable participants to stage plays in the community to raise awareness regarding sexual health and (6) to enable participants to monitor and evaluate activities.

The workshop started with core sexual health modules. 'Personal ethics' made clear the importance of self-respect and respect for others by being non-judgmental in order for one to better protect, care for and enjoy ones body and mind. 'Sexual health' explored the concepts of sexuality and its importance in the general health status of individual including the physical, psychological and social aspects. 'Sexual rights' spoke of rights, their origins and why they are important for healthy sexuality. The above modules provided the comfort level to understand and discuss sexual health issues more openly. Modules were also run on specific theater games and drama techniques, which helped participants in their performances. These included communication skills (verbal and non-verbal), voice modulations, mime, creativity, story and character building and the stages of a drama. Participants were taken through the stages of TfD, i.e. research, story telling, story building, drama making, drama testing, performance and feed back. Sexual health scenarios were used whenever possible. A field trip was also arranged to give an opportunity to participants to practice active listening and identify real life stories and issues of the local community. The end result of the workshop was a reality-based play on early marriage, gender roles and infanticide, based on a true story that had recently occurred in the community where the play was to be performed. A twenty-minute play was performed at the adolescent health center of a local NGO. Approximately 30 people of various ages, but all males attended the play. It was followed by 20 minutes of discussions between the audience and the performers on issues identified in the play. All the audience appreciated the play, especially the fact that it was based on a real life situation. According to one participant,"I loved the play because it was based on problems of my area."

Participants agreed that child marriages were a serious issue needing attention. The mother's cries as her father kills her girl child, even though played by a man, created a shocked silence that was almost tangible. Participants were eager to participate in other plays the group may perform.

Statements like, "we do treat our women so bad…we must treat them with respect and honor" signify the realization that the women in the play represented their own women folk and that these events affected them in real life also.

As mentioned earlier, the female participants did not take part in the actual play because of 'perceived' cultural sensitivities. However, the audience thought that women should participate, both as actors and audience. One participant mentioned that " women should play women's parts…. If there was some arrangement for women here, I would like the women of my family to see this play."

Learning statements were regularly collected during the workshop and discussed in the start of each day. Some of these statements reflect on the use of theater for development to explore and understand culturally sensitive issues. Perhaps the most exciting outcome of the workshop was a realization by participants that sexual health was an important aspect of one's life and the comfort with the subject that followed and mentioned that they " found the guts to talk about sexual health" and that "shame and hesitance is gone". Another male participant reported that he always thought, " sexual health was a dirty subject". He went on to say that endeavors to start improving our sexual health "should start in our houses". Another important outcome was the realization that taboo or not, attitudes regarding sexuality was amenable to change with self-reflection and perseverance. Several participants mentioned that they "may be able to change people's minds". According to one female participant, "We can better understand…. The cruelty happening in our own houses…. We can tell people now".

One particular problem working in Pakistani communities is that men and women may not have the confidence or be accepted by society to have a common dialogue. Participants claimed to have gained "confidence about communication with the opposite sex" and communication skills in general. One male participant while talking about the importance of eye contact for successful communication said, "I never realized that eyes have a language of their own…I used to be ashamed of looking a woman in the eyes"

Perhaps the most important of outcomes of the workshop was the empowerment that participants felt they had in changing their behaviors for the better and influencing others also. They spoke of "everyone is important…and their thought processes must not be ignored". Male participants claimed to "realized for the first time about women's' rights" and pledged to "do so the same with the women of my house"

Participants were asked to give feedback on the workshop and the facilitators. On the whole, participants were very happy with the results of the workshop. Some of the suggestions given included the workshop should have been in Sindhi (the local language), longer duration and more female participants.

The Plays

In June 2003, the theater group of VDWA held a performance for men in their village. It was attended by approximately 150 men of all ages and held in the local high school ground. Two different plays were performed. The first, based on 'Lesson 4' from Aahung's Adolescent Manual, "The month of Ramazan', was a play about a young boy having his first wet dream and confused and worried about all the changes in his body and thoughts since he turned thirteen. With no one in the family to confide in, he turns to an older male servant for advice. The servant tells him that he has a serious 'men's disease' and takes him first to a spiritual healer who tells him that he is 'bad' is why he gets these 'dirty dreams', and then to a local 'hakeem' who prescribes him a lot of expensive medicines. The whole play was enacted a second time but this time after every scene the audience was asked to suggest changes as they thought appropriate and in this way messages incorporated in a participatory method. The issues addressed included knowledge about the normal changes in adolescence, the importance of giving this information to boys and how to give it, and protecting one's body from harm and unprotected sexual activity.

The second play was based on 'Lesson 3' from Aahung's Adolescent Manual, "Visiting the health care provider". It was a comedy play of a man visiting an un-qualified health practioner and portrayed how the such providers con their customers to make money, sell unsafe potions and often cause more harm rather than cure. The messages delivered included to avoid visiting the health care provider unnecessarily, how to recognize a quack, how to give a proper history and demand quality care as a personal right.

The plays were followed by a discussion where many problems were raised, questions asked and myths clarified by the Aahung team.

Conclusion

We learned through this experience that Theater for Development is an authentic, acceptable and reliable developmental tool which is easily understood, appreciated and enjoyed by the community. It is a relatively inexpensive intervention that can be utilized to discuss sensitive issues and explore community believes and challenge them in a non-hostile manner.

Even though TfD may not merit a place on a list containing PHC, education, child rights and poverty, it can make a significant contribution in all these areas. For a culturally sensitive issue like sexual health, it is evident that simple health messages over the radio or pamphlets distributed at the health center may not be very effective interventions by themselves. TfD, because of it's participatory note, lack of dependence on technology or literacy and it's ability to exploit indigenous forms, is one form which is most able to respond to the need to be context specific when dealing with grass root self development.

The case study points towards the practicality and soundness of using innovative methods for community mobilization, health promotion of sensitive topics like sexual and reproductive health and male involvement in issues like reproductive health.

References

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Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: